Jun

19

By RONI CARYN RABIN
Published: June 19, 2007
The New York Times
Advances in radiology have radically transformed medical practice, with CT scans and nuclear medicine exams providing physicians with the ability to quickly pinpoint internal bleeding, diagnose kidney stones or confirm appendicitis, assess thyroid function and identify and open blockages in the blood vessels to the heart.

The downside is that Americans are being exposed to record amounts of ionizing radiation, the most energetic and potentially hazardous form of radiation.

According to a new study, the per-capita dose of ionizing radiation from clinical imaging exams in the United States increased almost 600 percent from 1980 to 2006. In the past, natural background radiation was the leading source of human exposure; that has been displaced by diagnostic imaging procedures, the authors said.

“This is an absolutely sentinel event, a wake-up call,” said Dr. Fred A. Mettler Jr., principal investigator for the study, by the National Council on Radiation Protection. “Medical exposure now dwarfs that of all other sources.”

The study, financed by the federal government, is to be published by early next year. It found a particularly sharp rise in the number of CT scans — to 62 million in 2006, from 3 million in 1980. Though CTs make up only 12 percent of all medical radiation procedures, they deliver almost half of the estimated collective dose of radiation exposure in the United States. A CT scan exposes patients to far more radiation than a standard X-ray, and multislice CT scanners deliver higher doses of radiation than single-slice scanners.

Nuclear medicine exams increased to 18.1 million in 2006, from 6.4 million in 1980. They represent almost a quarter of the estimated collective radiation dose, with cardiac studies making up most of the dose.

X-rays have been classified as carcinogens by the World Health Organization, the Centers for Disease Control and Prevention and the National Institute of Environmental Health Sciences, because studies have shown that exposure causes leukemia and cancers of the thyroid, breast and lung.

Yet with the exception of mammography, scans remain largely unregulated. (The Food and Drug Administration regulates manufacturers of equipment but does not inspect facilities, which are licensed by states. Radiation doses for mammography are limited by federal law.) Radiation doses for the same procedure can vary drastically, as different machines in the hands of different practitioners deliver doses that vary by as much as a factor of 10, experts say.

Radiologists say they do not want to scare people away from having scans and exams when necessary, but they want patients — as well as physicians — to carefully evaluate the benefits and risks of each scan or exam, make sure the procedure is appropriate and keep track of cumulative exposure levels. Full-body CT scans should be avoided unless there is a good medical reason.

“We’re not saying you shouldn’t have X-rays or CT scans — they’re wonderful, they’ve totally revolutionized the practice of medicine,” said Dr. E. Stephen Amis Jr., a former president of the American College of Radiology who is chairman of radiology at Albert Einstein College of Medicine and Montefiore Medical Center in New York. “But if you go into the emergency room with recurrent pain and get a CT scan every time you show up, that’s not good. Use a little common sense.”

Studies of atomic bomb survivors in Japan found a statistically significant increase in cancer at high levels of exposure — 50 millisieverts, or mSv, about 16 times the current annual average for Americans from medical exams. But that figure is controversial; it is not clear that lower levels of radiation exposure are safe. Nor would it be unusual for a patient to exceed this level, according to a recent paper from the American College of Radiology.

“It is worth noting that many CT scans and nuclear medicine studies have effective dose estimates in the range of 10 to 25 mSv for a single study, and some patients have multiple studies; thus it would not be uncommon for a patient’s estimated exposure to exceed 50 mSv,” the paper said, adding that “the International Commission on Radiological Protections has reported that CT doses can indeed approach or exceed levels that have been shown to result in an increase in cancer.”

A single CT scan of the abdomen, body or spine can expose a patient to 10 mSv, according to the American College of Radiology patient information Web site (www.radiologyinfo.org, see Safety). Mammography, on the other hand, delivers only 0.7 mSv, and a bone-density scan is only 0.01 mSv.

There are several steps patients can take to protect themselves, and they should not be shy about asking questions, doctors and other experts say.

“They can always inquire of the referring physician, ‘Is this test necessary?’ ” said Richard Morin, chairman of the radiology college’s quality and safety committee, adding that “exams are often done for reasons that are not quite appropriate.”

Doctors should be familiar with the radiology college index of appropriateness criteria, which rates the imaging procedures for some 200 medical conditions. Dr. Morin suggests asking the doctor ordering the test about its rating for a given condition.

Scores range from 1 to 9, he said, and “if the number turns out to be 1 or 2, you should look for some other exam.”

When undergoing a scan or exam, patients should try to use a facility accredited by the American College of Radiology. The accreditation, which is voluntary, means the machines are surveyed and calibrated to use the correct level of radiation and the technologists are certified. It also means the images are likely to be of higher quality, reducing the likelihood of having to repeat a procedure and suffer additional exposure.

Research studies closely regulate and monitor radiation doses, so participating in a research study may provide some protection, Dr. Morin said. Hospitalized patients are also often scanned routinely once a day when they are very ill, he said, and “it’s not unreasonable for someone to ask, ‘Do I really need this exam every day?’ ” Patients may also want to ask the radiologists or technicians whether the machines are routinely inspected by a medical physicist.

Women should tell the doctor or technician if they might be pregnant; generally, women, children and young people should try to avoid scans.

If patients are given a CD of their scan, along with the interpretation, they should hold onto it, to avoid having to repeat a procedure. People who are undergoing multiple studies may want to keep a record tracking all the radiological procedures they have had, and inform their physicians of their history, said Dr. Amis, of Albert Einstein.

“Patients should have a questioning demeanor when going in for any kind of health care,” he said. “Unfortunately, the majority do not.”

Jun

19

Target Health Inc. is proud to be a contributor to The Millennium Villages project, supported by The Earth Institute at Columbia University, Millennium Promise, the United Nations Development Programme, and the UN Millennium Project. Columbia University’s Professor Jeffrey Sachs MD is the Head of The Earth Institute.

NEW YORK, June 15, 2007 – A new initiative from Columbia University Medical Center will be the first to target chronic oral health problems in sub-Saharan Africa, where the vast majority of chronic diseases are left undetected and untreated. The initiative is the result of an anonymous $1.5 million gift to support the Millennium Villages, which aims to fight extreme poverty and related challenges such as disease, hunger and lack of access to water and sanitation though scientifically sound and sustainable interventions. A third of the gift will be devoted to supporting the oral health program.

Dr. Syrop in Ethiopia

Dr. Steven Syrop and a patient in Koraro, Ethiopia

Chronic diseases will soon become the leading cause of health problems in the developing world, and oral health conditions are one of the most common chronic disorders, according to the World Health Organization. Initial Columbia research in the village of Koraro, Ethiopia, found that more than half of the population complained of oral pain. The generous donation will fund the first extensive initiative, led by Columbia’s College of Dental Medicine, to directly target oral health problems in sub-Saharan Africa with a sustainable prevention and treatment program.

“Oral health is important to total health, so it’s essential that efforts to improve the lives of impoverished communities include a dental component,” said Ira Lamster, DDS, dean of the College of Dental Medicine at Columbia University Medical Center. “The faculty and students of Columbia’s College of Dental Medicine are committed to addressing the global epidemic of chronic oral health problems through treatment and prevention programs.”

“There is currently no access to dental care whatsoever in the remote villages of the world,” said Steven Syrop, DDS, associate clinical professor of dentistry at the College of Dental Medicine, who is leading the dental component of the Millennium Villages. “There are only 48 dentists in the entire country of Ethiopia, and most are in the capital, Addis Ababa. We’re going to bring dental care to villages where there are no dentists.”

Dental student Jeff Laughlin and Dr. Syrop in Koraro, Ethiopia

The health component of the Millennium Villages grew out of the United Nations Millennium Project and the World Health Organization Commission on Macroeconomics and Health, both of which showed the direct link between improving public health and economic growth. Those reports explained that health improvements can only happen through a broad range of inter-related public health reforms.

The Millennium Villages project, supported by The Earth Institute at Columbia University, Millennium Promise, the United Nations Development Programme, and the UN Millennium Project, currently includes 12 sites in 10 sub-Saharan countries. It reaches more than 400,000 people with plans to increase its reach over time. The project empowers the local health care sector by supporting basic health interventions, building or upgrading clinics, and expanding the pool of community or village health workers. The participating villages are integral partners in the project and take responsibility for the interventions.

In addition to the oral health initiative, the new funding will support Columbia-led interventions to address chronic cardiovascular and mental health disorders in the region.

The dental component of the project is the result of research by Dr. Syrop and his team, who traveled to Koraro, Ethiopia, in the fall of 2006 to assess the oral health situation in the village of 5,100 people. In addition to the common complaint of oral pain, the team found a high incidence of hardened plaque (calculus) and gingival bleeding. Ninety-five percent of the people they examined had significant dental erosion because of the presence of sand in their food as a result of the arid environment and lack of water for rinsing crops.

“We were surprised by the extent of the oral health crisis in Ethiopia,” said Dr. Syrop. “In an area where the population has little access to sugary food and fermentable carbohydrates, we didn’t expect the problem to be as bad as it is. Developing a sustainable oral health program is an essential ingredient to improving the lives of these people.”

Teams of five or so Columbia faculty, staff and students will travel this fall to sub-Saharan countries, including Tanzania, Rwanda and Senegal, to collect data and assess the population’s oral health needs. They will use the data to develop a program for three or four villages initially, and then ultimately incorporate oral health as an integral component of improving health care at all of the Millennium Village sites.

The Columbia teams will train local health care workers to provide basic essential dental care, including extractions and control of infections. Additionally, the teams will introduce a comprehensive prevention program in the schools and the overall community by working with local teachers to develop a curriculum that is appropriate and sustainable for the individual village. They also will develop a prevention program to educate mothers about caring for the oral health of their young children.

“Treating and preventing oral health problems is one spoke in the wheel of improving conditions in sub-Saharan Africa,” said Dr. Syrop. “By improving their health, we enable this population to be more productive, helping them to improve their economic situation and lift themselves out of poverty.”

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Columbia University Medical Center provides international leadership in pre-clinical and clinical research, in medical and health sciences education, and in patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, nurses, dentists, and public health professionals at the College of Physicians & Surgeons, the College of Dental Medicine, the School of Nursing, the Mailman School of Public Health, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. www.cumc.columbia.edu

Jun

19

New vaccines are available to make significant gains against cervical cancer deaths and debilitating pain from shingles, but infectious diseases experts warn that their full potential will not be realized without changes in the way vaccines for adults and adolescents are promoted, financed, and delivered in the United States.

The Infectious Diseases Society of America (IDSA) has released a new “blueprint for action” to prevent tens of thousands of deaths and illnesses caused by these and other diseases that can be avoided with a few simple shots. The blueprint is published in the June 15 issue of Clinical Infectious Diseases.

“We have done a great job in this country delivering vaccines to children, but we have done an awful job delivering vaccines to adults,” said Neal A. Halsey, MD, professor at the Johns Hopkins University Bloomberg School of Public Health and chair of the IDSA Immunization Work Group that developed the policy blueprint.

For example, he points out that more than 90 percent of U.S. children are immunized against measles, mumps, whooping cough, hepatitis B, and other diseases. Rates of these diseases are at or near historic lows. In contrast, an estimated 175,000 adults are hospitalized and 6,000 die each year from pneumococcal pneumonia, but one in three adults over 65 has not been vaccinated against it. The Centers for Disease Control and Prevention (CDC) estimates that the cost of treating diseases that vaccines could prevent exceeds $10 billion annually.

Cost is one factor in why adults do not get vaccinated–particularly the uninsured. “CDC has very effective systems for delivering vaccines to underserved children,” said IDSA work group member Walter A. Orenstein, MD, associate director of the Emory Vaccine Center and former head of CDC’s immunization program. “One of them is Section 317 of the Public Health Service Act, which helps state and local health departments provide vaccines to uninsured or underinsured patients–largely children–for free. Section 317 must now be expanded to catch underserved adults at highest risk.”

While the program is cost-effective, expanding Section 317 will require a significant infusion of cash. Section 317’s current $520 million budget will need an additional $170 million per year in order to cover all vaccines for uninsured adults, according to a recent CDC estimate. “It is essential that we provide adults access to these vaccines that save lives and prevent illnesses,” Dr. Orenstein said, “but immunizing adults must not be done at the expense of children.”

IDSA also is calling for all plans to cover all adult and adolescent vaccines recommended by CDC’s Advisory Committee on Immunization Practices and to pay physicians adequately for office costs associated with immunization. Further, managed care plans should be measured in part on how well they immunize patients. Another principle supports exploring where immunization can appropriately take place outside the traditional office setting. Funding to support research into vaccines and vaccine delivery must be increased, and resources must be available to gather data on safety, efficacy, and usage.

Physicians and patients also must be part of the solution, according to the IDSA blueprint. “Part of the problem lies with physicians, who are not accustomed to offering vaccines during routine visits with adult patients; and with patients, who are unaware the vaccines exist,” said IDSA work group member William Schaffner, MD, chair of the Department of Preventive Health at Vanderbilt University. Doctors who serve adults must begin assessing adult immunization needs during routine preventive health care visits. Also, CDC should launch an education campaign to help improve awareness about vaccines and the illnesses they can prevent in adults.

“As health care workers, we set an example for our patients,” Dr. Schaffner added. “We all must be fully immunized.”

“We have the tools to make dramatic improvements in adult and adolescent health, as we have for children,” said Andrew T. Pavia, MD, chair of IDSA’s National and Global Public Health Committee, Chief of Pediatric Infectious Diseases at the University of Utah, and a member of the National Vaccine Advisory Committee. “IDSA’s blueprint outlines the steps we must take to use these tools effectively. Now all we need is the will to take those steps.”

Reference: IDSA blueprint, “Actions to Strengthen Adult and Adolescent Immunization Coverage in the United States.”

Note: This story has been adapted, by Science Daily, from a news release issued by Infectious Diseases Society of America.